DISCLAIMER: The cases / examples on this blog have been anonymised to maintain confidentiality of patients. Cases have been acquired from various international hospitals and through other medical colleagues with the intention to teach through case examples.

Wednesday, 24 October 2007

In my time I have experienced many funny situations in my medical life.

I write this blog today because of a situation I saw just recently when I was walking in the street. I saw a female walking from one side of the road to the other wearing normal clothes and seemingly doing what a normal person would do. She made her way to the cigarette machine in the street and was looking for small change to buy the cigarettes. In the night time when this occurred, I saw something dangling from her arm which was shinning in the light from the oncoming cars headlamps. I thought that my eyes were deceiving me until I got a better look and I realised it was a drip tube. Suddenly, the patient picked up her drip bag of intravenous fluid she was having at the time. Yes, the patient was so unwell requiring intravenous fluid that she was able to get up and go out of the hospital to buy some cigarettes.

It also reminded me of when I was a first year doctor in London when I was treating a drug addict with cellulitis and anaemia. He required intravenous antibiotics and blood transfusions. However, the only available venous access was a small superficial vein in his neck to which the blood transfusion was attached. He soon went missing from the ward and despite searching for him, he had left the hospital with his blood transfusion still running!! On my way out of the hospital in the evening sunset, I saw the patient begging on the road trying to sell his blood transfusion to oncoming Londoners, no doubt so he could buy more drugs and use the intravenous access made for medical purposes as his no inlet for illicit drugs.... This was a desperate man who needed help and it showed to me just how far some people will go to try and maintain a drug habit.

At the same hospital, I was on-call one night when a patient was admitted with chest pain from a possible crises from sickle cell diseases. She was screaming for pethidine, a fast acting synthetic opioid drug that can be highly addictive. She was not from the local area and so after checking with several other hospitals to which she had been admitted with the same problem it became clear that she always asked for pethidine. At one point she grabbed hold of my arm and screamed at me to give her pethidine. I offered her other pain relief such as oral morphine as a substitute but she refused it. The reason is, oral morphine is good for pain relief but does not give a sudden "hit" that one gets from pethidine or heroin (diacetylmorphine). Hence, it became clear that the patient was after a fix of pethidine because of the unfortunate addiction that can occur from the treatment of sickle cell crises.... I felt sorry for the lady but she soon discharged herself from the ER department as she had failed to obtain the fast acting opioid she had been after.

Another example, was a man I saw when I was a medical student. He was admitted with severe pain in his loin radiating to his groin. He was writhing around in pain on the bed and was shouting for pain relief. His thermometer registered a fever and analysis of his blood revealed lots of blood. For all intents and purposes, any competent doctor would immediately investigate and treat as a renal stone plus infection. Renal stones can be very painful and sometimes NSAIDs do not take the pain away. In the end, he was given Entonox (nitrous oxide) that is also used more commonly during childbirth. He went through almost 2 large bottles of the stuff before the ER doctor decided to investigate things further.... After ringing other hospitals it soon became clear that the patient was a 'hospital hopper' and had been discharged from several other institutions with the identical same symptoms and was easily identifiable because of a unique tattoo on his arm. After being confronted, he got up as if nothing had happened and walked out the ER having succeeded in obtaining Entonox !He had put the thermometer up to the light bulb in his cubicle to give him a fever and had pricked his finger to put blood in his urine. I had been completely fooled.....as had almost all of the ER staff !!

Lastly, but by no means least, when I was a junior doctor on-call in ER, I saw an ER senior doctor seeing to a young man having seizures. However, the patient's type of the seizures was unusual as he did not have any prolonged confusion or tiredness i.e. no post-ictal state. Moreover, there was no tongue biting and no incontinence. The patient failed the drop test which involved dropping the patients arm onto his face. If the arm hits the face, the patient is unconscious, but if the patient is faking unconsciousness, unless they know about the test, they usually avoid hitting themselves! Following this, the ER doctor was suspicious of pseudoseizures and the purpose of the patient doing this was to obtain free IV benzodiazepine-- the treatment for seizures but also an addictive drug!!!

A consultant then saw the patient at which point he said the following-- 'we take the testicle and strike it hard with the tendon hammer. If the patient is truly unconscious he will not feel pain, but if he is faking it....' He then walked away from the patient pretending to go and find the tendon hammer. Within 1 minute the patient had jumped off the ER bed, now fully conscious, and shouted a few obscene words at the consultant and ER staff before running out of the hospital.....

I hope that you have enjoyed these few examples of unusual patients. Although such cases may seem humorous initially, each case described above involves an addiction of some sort which made these patients do something that is an unacceptable thing in normal society. Whether it be going to buy cigarettes wearing a drip or selling blood transfusions, such unusual actions show us as doctors that there are many people out there in the world with problems related to addiction to chemicals or drugs. How can we help such people?

Do you have any good examples of real cases you would like to share???? Please send your comments to my blog for us all to share.